House Insurance

Contact Details

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Name: Company Name:
Telephone: Mobile No:
Fax No: Email:
Address:
Post Code:
Date of Birth:
Occupation:

Household Insurance

Buildings Sum Insured: £

Contents Sum Insured:

 £ (If high risk items exceed one third, please advise)
Please tick if accidental damage cover is required:
Please tick if personal possessions away from home is required:
If ticked, please indicate maximum value: £

Is the home:

House
Detached Owner Occupied
Bungalow
Semi-Detached Rented
Flat
Terraced Other
Other
Other

Year Built: No. of Bedrooms:

YES
NO
Is the home unoccupied for more than 30 days at a time?
Is the home unoccupied during normal working hours?
Is the house used for any business or professional purposes?
Is the house fitted with 5 lever mortise deadlocks on all final exit doors?
Is the house fitted with key operated window locks on all accessible windows?
Is the house fitted with an intruder system?
Is there any history of subsidence or flood damage to your home or in the area?
Have you suffered any loss or damage or made any claims in the last 5 years?

If yes, please supply details:

Current Insurer:

Your house insurance renewal date:

Are there any other material facts which may affect this quotation? If yes, please supply details:
Additional Comments: